Injecting new life into harm reduction
Britain's success in containing the spread of HIV since the 1980s is one of its greatest public health achievements. But since then, says Russell Newcombe, our record on harm reduction has been feeble.
Reprinted by kind permission of DrugScope. Click here for more information about Druglink and how to get your copy https://www.drugscope.org.uk/druglink/default.asp
When I wrote the report High time for harm reduction in 1986 I had a strong intuition that interventions like needle exchange were the vanguard of an emerging 'damage limitation' approach to drug users. But I could not have foreseen just how widespread the harm reduction (HR) strategy and wider movement would become in Britain and across the world.
Having said that, progress within six particular domains - drug information, prescribing, needle exchange, consumption rooms, product identification and drug laws - has actually been fairly limited. And there are many other HR interventions beyond these six domains that remain virtually ignored. By 2005, the vast potential of the drug-related harm reduction model has barely been explored.
Obstacles
"The vast potential of the drug-related harm reduction model has barely been explored."
To my mind, this was because of the inevitable taming of the HR movement in the early 1990s. Its radical edge was toned down and its aims and methods were reconfigured by mainstream political policies and agendas - especially the new criminal justice crusade.
Of the numerous obstacles to progress, three were salient. Firstly, the assimilation of specialist drug services into generic, mainstream structures. Secondly, drug laws which discourage users from making contact with services for fear of being punished. And finally, strong resistance to change - at both organisational and individual levels - from the abstentionist camp, particularly medical professionals and 'drug preventionists'.
But there has also been a lack of creative imagination among HR policy-makers, and a continuing fear among professionals of 'raising your head above the parapet' by becoming publicly associated with radical ideas. Individual career plans, organisational regulations, apathy, ignorance and the pervasive mythology about drugs all conspire to keep drugs professionals from suggesting or supporting radical change. It's far safer and easier to support the status quo and hold the policy ratchet in place.
Mersey Model
The demise of harm reduction in Liverpool and the Mersey region [but with Wirral as a laudable exception] provides a good example of what has happened to HR at a national level. Liverpool was once regarded as one of the epicentres of the HR movement, but has now arguably become one of the worst cities in the country for such services.
A network of specialist building-based, mobile and outreach HIV prevention services has been replaced by about a dozen pharmacies offering a very limited, and often unfriendly, service - with some areas being 10 or 15 miles from the nearest scheme. Outreach teams have all but disappeared, apart from those doing educational work inside prisons and youth clubs, rather than make contact with drug users in the community, which was the original idea.
The radical prescribing regimes of Mersey Drug Clinics, notably in and around Liverpool in the late-80s and early-90s - including heroin, cocaine and amphetamine in oral, injectable and smokable forms - are long gone. They have largely been replaced by a monolithic methadone-dispensing machine.
Unsurprisingly, HIV and hepatitis risks have, along with the rest of England, increased dramatically in Merseyside, the use of needle exchange services has dropped right off and past-month needle sharing rates have risen from one in ten in the mid-90s to one in three now. Over a third are likely to be infected with hepatitis B or C, though HIV infection rates remain below one per cent. Despite the low HIV infection rates, an HIV epidemic among injectors is an ever present menace.
It is interesting that, apart from academics such as economists and social scientists, the most vocal supporters of HR and radical drug policy reform are police officers - often just retired, but the point remains. Drug workers and other helping professionals are far less likely to go public.
There are those who argue that harm reductionists should disassociate themselves from drug law reformists. They say the two movements have conflicting, or at least different, goals and that associating with them damages the credibility and reputation of the HR movement. Though they have different aims, legal reform is undoubtedly one of the main methods by which the reduction of drug-related harm can be achieved. HR and drug policy reform are in reality intimately connected.
Way forward
So what does British drug policy now need to get the HR approach up and running, in a way which allows its full potential to develop? At a general level, a wider understanding of drug-related HR is needed in order to allow the intelligent development of the strategy and efficient communication between practitioners, policy-makers and researchers.
Two decades of research into HR have led me to the following conclusions about what is needed.
• A return to more specialist, client-centred services for injecting drug users with a user-friendly style of service delivery that is non-judgmental, informal, anonymous and confidential. These services must have: flexible procedures for the provision and return of used injecting equipment; a wide variety of injecting equipment; outreach and mobile services for evenings and weekends; primary health care with tests for infectious diseases; and advice on safer drug use in consumption rooms.
• The revival and development of the old British system of drug treatment, with a flexible range of evidence-based options tailored to the needs of drug users. This requires the prescription, in addition to methadone and buprenorphine, of a range of opiate substitutes for heroin addicts such as morphine, diamorphine, and fentanyl. These need to be available in oral, smokable, sniffable and injectable forms. There needs to be far greater resources for a range of interventions to help people cease and recover from drug misuse - from rapid detox to long-term residential rehabilitation.
• The scientific exploration of techniques for screening people - particularly pre-teens - for genes or other physiological indicators of increased risk of addiction to particular drugs or negative responses to drugs. People could then be warned of possible risks from drug use. For instance, there is already evidence that there are genetic bases for addiction to alcohol and opiates, as well as genetic risks for such harmful outcomes as MDMA-induced hyperthermia and cannabis-induced psychosis.
• The prioritisation of scientific research into safer drug products. This would include botanical research to produce safer drug plants, pharmaceutical research to find alternatives to currently popular, but problematic drugs such as non-addictive opiates and non-toxic sedatives, and technological research to find ways of taking drugs which reduce their harmful effects, such as vaporiser pipes for smoking cannabis.
• Exploring interventions and research on the nightclub and dance scene. One of the greatest risks to health faced by drug users are the adulterants in drugs - not just ecstasy and heroin, but also in Britain's most popular illicit drug, cannabis resin, which is now mixed with all sorts of muck from engine oil to animal shit. Our drug strategy has done very little to deal with this problem. One option would be to hugely extend the present drug testing methods to a much larger operation involving the Forensic Science Service, local drug agencies, and local nightclubs.
• Legal reforms - notably decriminalisation and full legalisation - would do more to reduce the harmful effects of drug use than just about any other intervention. More minor and realistic reforms could be to distinguish social supply from commercial supply and the reclassification of drugs to reflect their actual risk and harm.
Hell's Kitchen
The best way of summing up the current state of the art is with a restaurant metaphor. HR is presently like a restaurant where they provide you with a really detailed menu telling you what's in each meal, pretty good table service from attentive waiters and clean crockery and cutlery to eat with. But where the food is poisonous, adulterated muck. I doubt anyone would want to eat there. Yet we expect drug users to attend services which do much the same - providing them with key workers, information on safer drug use and clean needles - while letting them use dirty, adulterated drugs.